The COVID-19 pandemic offers opportunities to study effects of in-utero and early life exposure to environmental changes. However, inferences from such studies may be flawed if the pandemic has changed the socioeconomic composition of parents. Analysing over 77.9 million live births from 15 countries, we estimate changes in the socioeconomic composition of the cohort born between December 2020 and December 2021 using interrupted time series analysis. We find that, compared with their counterfactual compositions, the December 2020-December 2021 birth cohort has a higher proportion of babies born to socioeconomically advantaged parents in Austria, England, Finland, the Netherlands, Scotland, Spain, Wales, and the United States while we observe the opposite change for Brazil, Colombia, Ecuador, and Mexico. These changes in cohort composition may cause between-cohort differences in life course outcomes that are influenced by parental socioeconomic circumstances even if early life exposure to the pandemic had no direct effect on this birth cohort.

Background Little is known about education-related inequalities in late-life disability. Here, we use individual-level register data on the receipt of the Austrian long-term care allowance (ALTCA) to assess education-related inequalities in the duration of late-life disability. Methods In this retrospective mortality follow-back study, we analyse receipt of ALTCA, a universal cash benefit based on physician-assessed disability in activities of daily living, during the last 5 years of life among all decedents aged 65 years and over from 2020 in Austria (n=76 772). Results The higher the level of education, the shorter the period for which ALTCA was received. Over the last 5 years of life, those with the primary/lower secondary education received ALTCA for 47% or 10 months (men), respectively, 38% or 12 months (women) longer than those with tertiary education. Education-related inequalities decreased with time to death and age at death. Conclusion We found education-related inequalities in the duration of late-life disability, that is, higher education was associated with a prolonged ability to live independently during the last years of life. Inequalities in disability decreased with time to death and age at death, pointing to a gradual levelling due to mortality-related declines as well as selective mortality.

Frailty is associated with adverse health outcomes in ageing populations, yet its long-term effect on the development of disability is not well defined. The study examines to what extent frailty affects disability trajectories over 15 years in older adults aged 50+. Using seven waves of data from the Survey of Health, Ageing and Retirement in Europe (SHARE), the study estimates the effect of baseline frailty on subsequent disability trajectories by multilevel growth curve models. The sample included 94 360 individuals from 28 European countries. Baseline frailty was assessed at baseline, using the sex-specific SHARE-Frailty-Instrument (SHARE-FI), including weight loss, exhaustion, muscle weakness, slowness, and low physical activity. Disability outcomes were the sum score of limitations in activities of daily living (ADL) and Instrumental ADL (IADL). Analyses were stratified by sex. Over 15 years, baseline frailty score was positively associated with disability trajectories in men [βADL = 0.074, 95% confidence interval (CI) = 0.064; P = .083; βIADL = 0.094, 95% CI = 0.080; P = 0.107] and women (βADL = 0.097, 95% CI = 0.089; P = .105; βIADL = 0.108, 95% CI = 0.097; P = .118). Frail participants showed higher ADL and IADL disability levels, independent of baseline disability, compared with prefrail and robust participants across all age groups. Overall, participants displayed higher levels of IADL disability than ADL disability. Study findings indicate the importance of early frailty assessment using the SHARE-FI in individuals 50 and older as it provides valuable insight into future disability outcomes.

Background: The prognosis for people living with HIV (PLWHIV) has improved tremendously in the past years, and life expectancy in PLWHIV is almost the same as in the general population. HIV now is regarded as chronic condition, and as PLWHIV age, additional age-related problems emerge. These seem to occur more often and earlier compared to the general population, due to the virus itself, due to antiretroviral therapy, or due to lifestyle factors. Among these problems are biological factors such as chronic non-communicable diseases, other communicable diseases, and frailty, mental factors like common mental disorders and substance use, as well as social factors like stigma, discrimination, prejudices, work disability and unemployment, and having no partner. It was the aim of this study to monitor medical health burdens in a cohort of PLWHIW over time with an emphasis on cardio-vascular risk factors in order to design a comprehensive, integrated, person-centred care model around the antiretroviral therapy. The study was carried out by researchers and caregivers together with PLWHIV, and supported by a pharmaceutical company. Methods: PLWHIV participated in a baseline study (2013) in an HIV treatment centre and in a follow-up study (2021). At baseline the study population comprised of consecutive patients with HIV, who visited their treating physicians for routine checks. Inclusion criteria were age >= 18 years, documented HIV-Infection and written informed consent. Risk factors were recorded as either having a corresponding diagnosis in the patient´s charts OR being treated with specific drugs, OR having laboratory values outside the normal range. Results: From the initially included 450 participants, 360 (80%) patients participated in the follow-up. The mean age at baseline was 41.4 years, 5.3% were female. 10.8% were affected by hypertension at baseline, and 19.6% at follow-up (P<0.001). Prevalence of type 2 diabetes mellitus was 3.1% at baseline and 5.3% at follow-up (P=0.039), and of dyslipidaemia 76.9% at baseline and 71.4% at follow-up (P=0.042). The proportion of smokers decreased from 42.6% a baseline to 37.1% a follow-up (P=0.007). Prevalence of overweight was 36.6% and of obesity 8.9% at follow-up (no baseline data available). Learnings and next steps: PLWHIV have a high prevalence of cardio-vascular risk factors in an early age, which will increase health problems as this population is ageing. Most cardio-vascular risk factors increased rapidly in PLWHIV and therefore they are a major challenge for comprehensive and integrated care. As an important next step not only medical, but also psycho-social, sexual, spiritual and lifestyle-related health burdens as well as health resources need to be assessed and monitored to ensure care for PLWHIV is truly person-centered. Furthermore, PLWHIV want to be perceived as a partner in their treatment and this needs to become an integral part of routine care.

A series of studies, including recent work published in BJOG by Rusconi et al.,1 has highlighted the surprising fact that measures of birth outcomes such as preterm birth and low birthweight improved 9 months after the first wave (February–June 2020) of the COVID-19 pandemic across countries such as Italy, Spain, Ireland and the USA (see Yang et al.2 for recent meta study). This growing body of work has generated important knowledge about the children conceived and born during the pandemic, and how they as a cohort may differ from those born before and after the pandemic. Yet, we believe that this strand of literature has overlooked key demographic drivers behind the changes in birth outcomes observed during the pandemic. Here we describe why an improvement in birth outcomes observed during the pandemic is likely caused by decline in conception rate and changing selection into conception in the months following the onset of the pandemic rather than changing behaviours among pregnant women during the pandemic. In their BJOG article, Rusconi et al.1 (p. 282) find that rates of preterm births declined drastically in September–November 2020 relative to trend, and they ask researchers to consider what lessons the pandemic may teach about the ‘possible importance of lifestyle and environmental aspects related to the occurrence of pregnancies ending preterm’. Others have noted the non-causal nature of these studies,3 which should be kept in mind for future research to cover. We, however, suggest a more fundamental aspect of the pandemic's effect on pregnancies has been overlooked broadly in the literature, which can account for most, if not all, of the decline found by Rusconi et al. and many other studies. The cause of decline in preterm births and other adverse birth outcomes should not necessarily be sought in changing behaviour or services during pregnancy, but rather in changes in how many and who conceived during the early stages of the pandemic,4, 5 as declines in conceptions and subsequent fertility rates have been observed across most developed countries.6 Figure 1 shows the monthly crude birth rate (CBR; number of births per 1000 population) for Italy for 2020 and 2021 measured relative to the 2019 monthly CBR. As clearly seen from the figure, the number of births declined drastically relative to 2019 starting September 2020 and until January 2021, with the CBR in January 2021 being 14% lower than what was observed in January 2019, which is the equivalent of 8.4 fewer births per 100 000 population that month. Rapidly declining birth rates are mostly caused by rapidly declining conception rates and are unlikely to be only explained by potential changes in pregnancy loss, abortion, maternal emigration or stillbirth rates. Mechanically, a decline in conceptions will manifest first as a decline in preterm births 7–8 months after the number of conceptions dropped.4 This is because (fewer) preterm babies, which were conceived after the pandemic onset, are born at the same time as full-term babies conceived before the COVID-19 pandemic. Thus, the decline in preterm rates can be seen as a demographic artefact caused by declining conceptions without any change to pregnancy-related behaviour occurring. In recent work, we have shown that a similar trend in fertility can be observed in Spain for the same period.4, 7 In this work, we also show a similar decline in Spanish preterm births rates as observed in Italy by Rusconi et al.4 Further, we demonstrate how this decline in preterm births can occur mechanically in the case of a rapid decline in conceptions right after the onset of the COVID-19 pandemic, which in turn leads to the observed lower birth rates beginning by September (fewer preterm births) and carrying out all through to January 2021 (fewer term births). Further, we also analyse changes in who conceives. In the Spanish case the data allow us to examine which groups see the largest conception declines. In relative terms, the two groups that see the largest decline are women at the beginning and end of the reproductive age – the two groups also at highest risk of giving birth to preterm babies because of, respectively, precarious and unplanned pregnancies occurring among the young8 and higher rates of complications and medically assisted reproductive (MAR) conceptions among older women.9 During the first COVID-lockdown, young people's risk for precarious and unplanned pregnancies declined drastically due to stay-at-home orders, and MAR clinics shut down services. Moreover, the COVID-19 pandemic has likely led to changes in the composition of parents in regard to other characteristics known to be associated with preterm birth.5 For example, initial evidence is emerging that babies conceived in the Global North during the pandemic have, on average, more socio-economically advantaged parents compared with babies conceived before the COVID-19 pandemic.5, 10 More advantaged parental socio-economic circumstances, in turn, have consistently been shown to be associated with a lower probability of preterm birth.11 Pandemic-induced compositional shifts in parental characteristics provide us with another plausible explanation for improved birth outcomes during the COVID-19 pandemic in the Global North, whereas the situation in countries with less universal access to contraceptive measures may have seen different developments, as suggested by Pesando & Abufhele12 for Chile. To conclude, the COVID-19 pandemic may have generated a pure demographic artefact driven by a population-wide decline in conceptions discussed above as well as heterogeneous conceptive responses across the affected populations. These two differential effects of the COVID-19 pandemic may also explain why babies conceived during the pandemic show improved birth outcomes compared with babies conceived before the pandemic. When interpreting the COVID-19 consequences on newborn health we thus advise disentangling the direct effect of in utero exposure to the COVID-19 pandemic and the consequences of lockdown measures on birth outcomes from a demographic artefact and pandemic-induced changes in the composition of who became pregnant. Importantly, the latter determinants and the former ones may have different clinical implications for the population of newborns and their long-term development trajectories. PF, MO and MC conceived, planned, carried out, analysed and wrote up the paper. All authors approved final version. Peter Fallesen was a visiting fellow at Department of Political and Social Sciences, European University Institute, during the writing of this commentary. PF's work was supported by ROCKWOOL Foundation (1227) and the Swedish Research Council for Health, Working Life and Welfare (2016-07099). MO's work was supported by the Medical Research Council (MC_UU_00022/2) and the Scottish Government Chief Scientist Office (SPHSU17). MC's work was supported by the Italian Ministry of the University and Research (PE8-B83C22004800006). None declared. Only publicly available secondary data were used for analysis and therefore are exempt from ethical approval. The data that support the findings of this study are available in ISTAT at http://dati.istat.it/. These data were derived from the following resources available in the public domain: ISTAT, http://dati.istat.it/.

Background: Status inequality is hypothesised to increase socioeconomic inequalities in health by creating an environment in which social cohesion erodes and social comparisons intensify. Such an environment may cause systemic chronic inflammation. Although these are often-used explanations in social epidemiology, empirical tests remain rare.Methods: We analysed data from the West of Scotland Twenty-07 Study. Our sample consisted of 1977 participants in 499 small residential areas. Systemic chronic inflammation was measured by high-sensitivity C-reactive protein (hs-CRP; <10 mg/L). An area-level measurement of status inequality was created using census data and contextual-level social cohesion was measured applying ecometrics. We estimated linear multilevel models with cross-level interactions between socioeconomic position (SEP), status inequality, and social cohesion adjusted for age and gender. Our main analysis on postcode sector-level was re-estimated on three smaller spatial levels.Results: The difference in hs-CRP between disadvantaged and advantaged SEPs (0.806 mg/L; p = 0.063; [95%CI:-0.044; 1.656]) was highest among participants living in areas where most residents were in advantaged SEPs. In these status distributions, high social cohesion was associated with a shallower socioeconomic gradient in hs-CRP and low social cohesion was associated with a steeper gradient. In areas with an equal mix of SEPs or most residents in disadvantaged SEPs, the estimated difference in hs-CRP between disadvantaged and advantaged SEPs was-0.039 mg/L (p = 0.898; [95%CI: 0.644; 0.566]) and-0.257 mg/L (p = 0.568; [95%CI: 1.139; 0.625]) respectively. In these status distributions, the gradient in hs-CRP appeared steeper when social cohesion was high and potentially reversed when social cohesion was low. Results were broadly consistent when using area-levels smaller than postcode sectors.Conclusions: Inequalities in hs-CRP were greatest among participants living in areas wherein a majority of residents were in advantaged SEPs and social cohesion was low. In other combinations of these contextual characteristics, inequalities in systemic chronic inflammation were not detectable or potentially even reversed.

Understanding the emergence of and changes in socioeconomic inequalities in lifespan requires reliable, longitudinal data. In the absence of administrative data, published obituaries may be one such alternative source. With the validity of drawing relevant data from obituaries not yet established in population health research, this study addresses this gap by estimating socioeconomic inequalities in lifespan in Vorarlberg, Austria. Data for all individuals (n = 1490) with obituaries published (July to December 2022) in a regional newspaper (market share: 56%) were extracted, including different markers of the deceased's socioeconomic status. Linear regression analyses showed that, on average, individuals with medium-sized obituaries lived 6.02 years (95% CI: 4.19, 7.85) and individuals with the largest obituaries 12.04 years (95% CI: 7.04, 17.04) longer than individuals with small obituaries while blue-collar workers lived 10.50 years (95% CI: -14.51, -6.49) shorter than individuals with no occupation (reported). This socioeconomic gradient is in line with findings based on national data sources, and comparisons with official regional data are promising regarding data representativeness and completeness. With obituary size reflecting different costs (€210–€1626) and thus being a novel marker for financial ability, obituaries could also be a useful, innovative data source internationally for historical analyses or “nowcasting” health inequalities.

Abstract Background In some high-income contexts, the COVID-19 pandemic was associated with improved birth outcomes, which was hypothesised to be caused by a positive effect of the pandemic on maternal health. Conversely, an improvement in birth outcomes may have been driven by pandemic-induced compositional changes in parental characteristics, which are associated with health outcomes at birth. Research on this consequence of the COVID-19 pandemic is critical for understanding pandemic-induced changes in population health (inequalities) and planning of public service provision. Methods We analysed population-wide data on birth outcomes and parental sociodemographic characteristics from Finland collected between January 2015 and December 2021 (n = 336,000). The total effect of pandemic-induced compositional changes on birth weight and preterm birth rate was estimated by segmented regression models using three conception cohorts: a) conceived prior to May 2019, b) conceived between June 2019 and February 2020 (to account for in-utero exposure to the pandemic), and c) conceived during the pandemic between March 2020 and February 2021 (to prevent selection bias). Preliminary Results Adjusting for secular trends and seasonality, and accounting for in-utero exposure to the pandemic, the estimated effect of parental compositional change on average birth weight was 36.5 grams [95%CI: 24.8; 48.3]. Correspondingly, this compositional change was associated with a 16.2% [95%CI: 8.8%; 23%] lower risk of preterm birth for babies conceived during the pandemic. Conclusions Pandemic-induced changes in parental composition drove the modest increase in birth weight and substantial reduction in preterm births for babies conceived during the pandemic. Should the postponed pregnancies among population groups at risk for worse birth outcomes eventually realise post-COVID-19, health care and educational systems may need to prepare for cohort-specific variations in service demand. Key messages • Improvement in birth weight and preterm birth rate among babies conceived during the COVID-19 pandemic were driven by pandemic-induced changes in parental composition. • Further research using natural experimental designs on this compositional change and health outcomes can inform future public service provision.

IntroductionThis protocol outlines aims to test the wider impacts of the COVID-19 pandemic on pregnancy and birth outcomes and inequalities in Scotland.Method and analysisWe will analyse Scottish linked administrative data for pregnancies and births before (March 2010 to March 2020) and during (April 2020 to October 2020) the pandemic. The Community Health Index database will be used to link the National Records of Scotland Births and the Scottish Morbidity Record 02. The data will include about 500 000 mother–child pairs. We will investigate population-level changes in maternal behaviour (smoking at antenatal care booking, infant feeding on discharge), pregnancy and birth outcomes (birth weight, preterm birth, Apgar score, stillbirth, neonatal death, pre-eclampsia) and service use (mode of delivery, mode of anaesthesia, neonatal unit admission) during the COVID-19 pandemic using two analytical approaches. First, we will estimate interrupted times series regression models to describe changes in outcomes comparing prepandemic with pandemic periods. Second, we will analyse the effect of COVID-19 mitigation measures on our outcomes in more detail by creating cumulative exposure variables for each mother–child pair using the Oxford COVID-19 Government Response Tracker. Thus, estimating a potential dose–response relationship between exposure to mitigation measures and our outcomes of interest as well as assessing if timing of exposure during pregnancy matters. Finally, we will assess inequalities in the effect of cumulative exposure to lockdown measures on outcomes using several axes of inequality: ethnicity/mother’s country of birth, area deprivation (Scottish Index of Multiple Deprivation), urban-rural classification of residence, number of previous children, maternal social position (National Statistics Socioeconomic Classification) and parental relationship status.Ethics and disseminationNHS Scotland Public Benefit and Privacy Panel for Health and Social Care scrutinised and approved the use of these data (1920-0097). Results of this study will be disseminated to the research community, practitioners, policy makers and the wider public.

OBJECTIVES:This study was conducted to describe how population-level subjective well-being (SWB) evolved throughout the pandemic. STUDY DESIGN:Thirty waves of panel data representative of the Austrian population aged ≥14 years were collected between March 2020 and March 2022. Participants were quota sampled from a pre-existing online panel based on key demographics closely mirroring the Austrian resident population. METHODS:We present wave-specific means of SWB throughout 2 years of the COVID-19 pandemic next to the evolution of the pandemic (cases and deaths) and stringency of lockdown measures in Austria as well as estimate their bivariate correlations. RESULTS:The analysed sample consisted of 3,293 participants contributing to a total of 46,168 observations. All components of SWB - negative affect, positive affect and life satisfaction - showed population-level fluctuation between March 2020 and March 2022. The magnitude of these changes was small. Population-level SWB correlated with the incidence rate of COVID-19 deaths (negative affect: r = 0.69, positive affect: r = -0.70, life satisfaction: r = -0.47), the Stringency Index (negative affect = 0.50, positive affect = -0.47, life satisfaction = -0.47) and less so with the incidence of COVID-19 cases (negative affect = 0.43, positive affect = -0.31, life satisfaction = -0.38). CONCLUSIONS:Population-level SWB fluctuated in accordance with rises and falls in COVID-19 cases and deaths as well as with the stringency of lockdown measures. This connection suggests that incidence of COVID-19 cases and deaths, as well as public health measures to contain the pandemic affect population-level SWB and could thereby impact population health and productivity.

The Author(s) 2022. Published by Oxford University Press on behalf of the European Public Health Association. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons. org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com https://doi.org/10.1093/eurpub/ckac049 Advance Access published on 5 May 2022 . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . Commentary . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . The LoCo (Lockdown Cohort)-effect: why the LoCo may have better life prospects than previous and subsequent birth cohorts

The relationship between social cohesion and health has been studied for decades. Yet, due to the contextual nature of this concept, measuring social cohesion remains challenging. Using a meta-analytical framework, this review's goal was to study the ecometric measurement properties of social cohesion in order to describe dissimilarities in its measurement as well as bring a new perspective on the empirical usefulness of the concept itself. To this end, we analysed if, and to what extent, contextual-level reliability and intersubjective agreement of 78 social cohesion measurements varied under different measurement conditions like measurement instrument, spatial unit, ecometric model specification, or region. We found consistent evidence for the contextual nature of social cohesion, however, most variation existed between individuals, not contexts. While contextual dependence in response behaviour was fairly insensitive to item choices, population size within chosen spatial units of social cohesion measurements mattered. Somewhat counterintuitively, using spatial units with, on average, fewer residents did not yield systematically superior ecometric properties. Instead, our results underline that precise theory about the relevant contextual units of causal relationships between social cohesion and health is vital and cannot be replaced by empirical analysis. Although adjustment for respondent's characteristics had only small effects on ecometric properties, potential pitfalls of this analytic strategy are discussed in this paper. Finally, acknowledging the sensitivity of measuring social cohesion, we derived recommendations for future studies investigating the effects of contextual-level social characteristics on health.

Abstract Background The economic and social disruptions caused by the COVID-19 pandemic and its mitigation measures may have affected fertility unequally across social strata. If a compositional change in maternal socioeconomic characteristics is confirmed, counterintuitive changes in future population health - the LoCo-effect - are likely. Methods We analysed data from maternal inpatient discharge records containing births between January 2018 and November 2021 by Scottish Index of Multiple Deprivation (SIMD) quintile. We used monthly number of births before November 2020 to estimate expected monthly births after November 2020 and compared against observed births in each SIMD quintile. Further, we estimated associations between monthly average stringency of national mitigation measures (Stringency Index (0-100)) and births 9 to 13 months later using distributed lag models. Results Between November 2020 and November 2021, there were 1301 (10.3%) fewer births than expected for the most deprived quintile (Q1; 953 (8.7%) and 375 (4.1%) less in Q2 and Q3). In the two least deprived quintiles, however, fertility remained mostly unchanged. A 10-point increase in monthly average Stringency Index in Q1 was associated with an average cumulative decrease of 8.5 births (95%CI: -14.1; -2.8, p = 0.006) 9 to 13 months later. Conversely, this estimate was a 4.4 increase (95%CI: 1.3; 7.5, p = 0.008) in Q5 and a 5.9 increase (95%CI: 1.4; 10.4, p = 0.013) in Q4. Conclusions Apart from their exposure to pandemic and lockdowns, it is likely that, due to compositional changes in births, the observed LoCo started life, on average, more socially advantaged than previous birth cohorts in Scotland. We show a substantial decrease in fertility in the most deprived areas, while fertility remained little changed in the least deprived areas. Increases in the stringency of lockdown measures were associated with a decrease in births in the most deprived but an increase in the least deprived areas 9 to 13 months later. Key messages • Between November 2020 and November 2021, there were substantial decreases in births among deprived areas in Scotland while fertility in the least deprived areas remained mostly unchanged. • For these births, the observed compositional shift in maternal socioeconomic characteristics may lead to changes in current and future health and health needs – the LoCo (Lockdown Cohort)-effect.

Abstract Background mixed evidence exists on the association between muscle strength and mortality in older adults, in particular for cancer mortality. Aim to examine the dose–response association of objectively handgrip strength with all-cause and cancer mortality. Study Design and Setting data from consecutive waves from the Survey of Health, Ageing and Retirement in Europe comprising 27 European countries and Israel were retrieved. Overall, 54,807 men (45.2%; 128,753 observations) and 66,576 women (54.8%; 159,591 observations) aged 64.0 (SD 9.6) and 63.9 (SD 10.2) years, respectively, were included. Cox regression and Fine-Grey sub-distribution method were conducted. Results during the follow-up period (896,836 person-year), the fully adjusted model showed the lowest significant risk estimates for the highest third of handgrip strength when compared with the first third (reference) in men (hazard ratio [HR], 0.41; 95% confidence interval [CI], 0.34–0.50) and women (HR, 0.38; 95% CI, 0.30–0.49) for all-cause mortality. We identified a maximal threshold for reducing the risk of all-cause mortality for men (42 kg) and women (25 kg), as well as a linear dose–response association in participants aged 65 or over. No robust association for cancer mortality was observed. Conclusion these results indicate an inverse dose–response association between incremental levels of handgrip and all-cause mortality in older adults up to 42 kg for men and 25 kg for women, and a full linear association for participants aged 65 years or over. These findings warrant preventive strategies for older adults with low levels of handgrip strength.